When in danger, when in doubt, just remember – deep breath in, deep breath out

ResearchBlogging.org It was a physio who first chanted that wee slogan at me some ten years ago… for a physio, he wasn’t bad at all! Come to think of it, I have worked with some great physiotherapists (please don’t let them know!).  Anyway, it’s been one of those sayings that I’ve carried with me ever since he taught me, and it actually works.

One of the simplest, easiest and least intrusive coping strategies for pain has to be diaphragmatic breathing. I’ve always thought it work partially because it buys a little time – a bit like ‘counting to ten’ to stop you losing your temper! And I’ve often used breathing techniques because it works so quickly on physiological arousal…it’s one of the few aspects of arousal level that we can consciously control, and by reducing the speed and increasing the depth of respiration, changes in heart rate are subsequently noticed, as well as gradual reduction in overall alertness and arousal level.

In this paper by Zautra, Fasman, Davis and Craig (in press), an experiment is used to test whether breathing rate influences both the intensity and unpleasantness of experimentally induced thermal pain.  Women with no history of chronic pain, as well as a group of people with fibromyalgia (FM) were both included in the study.  It was hypothesised that FM patients would differ from healthy controls, showing fewer effects of slow breathing on pain sensation because prior studies revealed that they have difficulties in positive affect regulation.

I’m not going through the procedures used, you can read that yourself, but I’m going right to the results and then think about what this might mean for us clinically.

  • High heat applied to the participants produced higher pain intensity ratings – but slowed breathing rates reduced this effect (producing lower pain ratings) but this was only in the case of the healthy participants.
  • In terms of unpleasantness – higher pain intensity also produced higher unpleasantness ratings, and once again slowed breathing reduced this, but mainly in people without fibromyalgia.
  • For affect, slow breathing led to lower negative affect during pain trials compared to normal breathing (t(663) = 5.45, p < .001), with no difference found between people with or without fibromyalgia.  Something that was observed, however, was that people with fibromyalgia tended to report reducing levels of positive affect as the testing progressed.
  • The tendency to be generally negative in affect (NA) was associated with less effect from slower breathing rate – A four-way interaction was found between breathing rate, pain stimulus, trait positive affect (PA), and trait negative affect (NA) predicting pain unpleasantness: F(1, 661) = 7.99, p < .005, and pain intensity ratings: F(1, 661) = 4.55, p = .033.
  • Participants with higher trait level PA combined with higher trait level NA had slightly lower pain ratings in response to the moderate pain stimulus when breathing more slowly. These effects did not vary by diagnosis.

So, what this shows is slow breathing has its greatest effects on ratings of pain stimuli of moderate in comparison to mild intensity, FM participants benefited less from slow breathing than healthy controls, and breathing rate didn’t seem to influence NA or PA.  People with fibromyalgia were less able to sustain positive affect gains from slow breathing than the healthy controls.

These findings suggest that self regulation, especially affect regulation, has an important role to play in coping with pain. It doesn’t look to be a straightforward role, and probably we’ll learn more about it over time – but it does seem that being somewhat negative by nature can influence the unpleasantness of pain.  That’s important because it’s distress about the meaning of pain (ie the judgement of how unpleasant the pain is) thatoften  leads people to seek treatment.

What it also shows is that simply teaching people to breathe slowly is going to provide some people, but not all, with a tool to cope with moderate to higher levels of pain – it doesn’t help so much when pain is lower.  If someone has trouble with self regulation, particularly affect regulation, chances are that they will have trouble coping with pain – and breathing slowly will not necessarily help as much as we would like.

The authors conclude that ‘From these results we may infer that slow breathing facilitates emotional regulation and the maintenance of homeostasis under the challenging conditions of acute pain induction. The effects of breathing rate on pain responses varied as a function of both level of pain and FM diagnosis. Indeed, the relative weak effects of slow breathing on outcomes for FM patients suggests that this group has particular difficulty in the maintenance of emotional equilibrium, due perhaps in part to a less differentiated affect system.’

They go on to describe further neurophysiological processes that underpin the role of breathing and homeostasis. Theory drives this particular approach to understanding pain.  The theory is that in some people the neurophysiological processes underpinning affect regulation (and hence pain perception) are awry.  When pain is perceived, instead of being able to active pathways that help to remain calm and able to maintain positive affect, in vulnerable people the pathways are inactivated, allowing increased arousal, greater negative affect and difficulty down-regulating the whole system – in effect, winding the whole response up.  This is something I’ll be looking at over the next month or so.

The question for us as therapists is whether we can teach people how to overcome this difficulty with self regulation.  While helping people learn how to breathe more slowly is part of a set of  pain management strategies, it’s not enough for some people.  As the authors state: ‘…the data suggest that meditative breathing alone is insufficient. Clinical interventions that address positive affective disregulation, appear necessary to assist FM patients in the management of their chronic pain.’

This means things like becoming aware of negative bias when thinking about and evaluating a situation; being able to notice good things as well as not so good; being able to be mindful rather than judgemental about situations; being actively involved doing positive activites; and building on resilience and strengths that people bring to their situation with pain.

Zautra, A., Fasman, R., Davis, M., & Craig, A. (2010). The effects of slow breathing on affective responses to pain stimuli: An experimental study Pain DOI: 10.1016/j.pain.2009.10.001


    1. You’re welcome Bas – I’ll do some more writing about self regulation and affect regulation, it’s really interesting and a developing area for research. I’m guessing people with FM will also need cognitive strategies and behavioural rehearsal/exposure to help develop self regulation skills, but breathing has always been one of the first things I’ve started on with people with this diagnosis.

  1. I’d be interested to see what the clinical effect of mindfulness meditation would be on pain and positive/negative affect. When I practice it, I often focus not just on breathing/the sensations in my body but also my reaction to the breathing/sensation in my body.

    If you don’t mind my mentioning it, I actually have a blog post about my own experiences with mindfulness meditation and chronic pain here: http://healinglesstraveled.wordpress.com/2010/01/28/skillful-reactions-to-pain/

    I wonder how one would test this clinically…

    1. Hi – that’s great to hear that you use this strategy, and thanks so much for the link to your blog. In terms of testing this sort of thing clinically, I think it’s now at the point where RCT is the way to go – this would mean testing two different types of relaxation, one of which is mindfulness, and identifying from the outcomes which one is most effective. I believe Lance McCracken from Bath University is studying this – and yes, I’ll be posting about it as soon as I find something! My understanding so far is that it’s not just the mindfulness meditation, but also the readiness to accept that pain IS without judging it or wanting to be rid of it, that is one of the critical factors. Of course, mindfulness meditation teaches that aspect of acceptance. My question is: how do we approach helping people develop this? Often their response can be ‘oh but I really DON’T want to accept that pain is going to be there, I really want it gone!’.
      Fear not, I will be posting more on this later on this month!

      1. Ooh, I’ll be excited to hear about the results of that research study.

        And yes, helping people develop a mindfulness practice depends on them wanting to change. I’ve been trying to get my mother to go to meditation practice with me for quite some time, and her response is usually that she’s “too busy” but wants to go “another time.”

        As they say, “you can lead a horse to water, but you can’t make it drink.”

        I do think, though, that if mindfulness meditation moves more into the mainstream – as in, recommended more often by doctors – that more people might try it. I’ve met a great guy who started meditating to deal with his substance addictions, and now meditates every day. It can really be transformative if people just give it a chance.

  2. I’m curious from reading this what follow up you may have posted, Bronnie? Can you direct me there?

    Also curious…why breath, breathwork, breath therapy tends to not be discussed much in discussions I see//hear/read about pain. Yes, you mention it’s not the only piece but as you mention above “breathing has always been one of the first things I’ve started on with people with this diagnosis”. Has this changed for you over the years?

    I’m off to search Lance’s work, so thank you for the info.

    1. I havent posted much on breathing since this one – odd because it is something I usually start with when I work with someone needing help with their pain! I may have moved away from the deep breathing part and more into mindful breathing now, with less focus on changing the breath and more on noticing the breath. I find that people do begin noticing the breath slows when being mindful – which is a useful learning for anyone with pain.

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